Form It-2104 - Employee'S Withholding Allowance Certificate - 2012
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7IT-2104
New York State Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
(1/12)
New York State • New York City • Yonkers
First name and middle initial
Last name
Your social security number
Permanent home address
Apartment number
( number and street or rural route )
Single or Head of household
Married
Married, but withhold at higher single rate
City, village, or post office
State
ZIP code
Note: If married but legally separated, mark an X in
the Single or Head of household box.
Are you a resident of New York City? .......... Yes
No
Are you a resident of Yonkers? .................... Yes
No
Complete the worksheet on page 3 before making any entries.
1.
1 Total number of allowances you are claiming for New York State and Yonkers, if applicable
.........
( from line 17 )
2.
2 Total number of allowances for New York City
.................................................................................
( from line 28 )
Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.
3 New York State amount ........................................................................................................................................
3.
4 New York City amount ..........................................................................................................................................
4.
5 Yonkers amount ....................................................................................................................................................
5.
I certify that I am entitled to the number of withholding allowances claimed on this certificate.
Employee’s signature
Date
Penalty — A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have
withheld from your wages. You may also be subject to criminal penalties.
Employee: detach this page and give it to your employer; keep a copy for your records.
Employers only: Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State
:
( see instr. )
A. Employee claimed more than 14 exemption allowances for NYS ........... A.
B. Employee is a new hire or a rehire .... B.
First date employee performed services for pay
:
(mm-dd-yyyy) ( see instr. )
Are dependent health insurance benefits available for this employee? ............ Yes
No
If Yes, enter the date the employee qualifies
:
( mm-dd-yyyy )
Employer’s name and address
Employer identification number
( Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department. )
Instructions
Changes effective for 2012
is different from federal Form W-4 or has changed. Common reasons for
completing a new Form IT-2104 each year include the following:
Form IT-2104 has been revised for tax year 2012. The worksheet
on page 3, the charts beginning on page 4, and the additional dollar
• You started a new job.
amounts in the instructions on page 2, used to compute your withholding
• You are no longer a dependent.
allowances or to enter an additional dollar amount on line(s) 3, 4, or 5,
• Your individual circumstances may have changed (for example, you
have been revised. If you previously filed a Form IT-2104 and used the
were married or have an additional child).
worksheet, charts, or the additional dollar amounts, you should complete
• You itemize your deductions on your personal income tax return.
a new 2012 Form IT-2104 and give it to your employer.
• You claim allowances for New York State credits.
Who should file this form
• You owed tax or received a large refund when you filed your personal
income tax return for the past year.
This certificate, Form IT-2104, is completed by an employee and given
to the employer to instruct the employer how much New York State (and
• Your wages have increased and you expect to earn $100,000 or more
New York City and Yonkers) tax to withhold from the employee’s pay. The
during the tax year.
more allowances claimed, the lower the amount of tax withheld.
• The total income of you and your spouse has increased to $100,000 or
more for the tax year.
If you do not file Form IT-2104, your employer may use the same number
of allowances you claimed on federal Form W-4. Due to differences in
• You have significantly more or less income from other sources or from
tax law, this may result in the wrong amount of tax withheld for New York
another job.
State, New York City, and Yonkers. Complete Form IT-2104 each year
• You no longer qualify for exemption from withholding.
and file it with your employer if the number of allowances you may claim
• You have been advised by the Internal Revenue Service that you are
entitled to fewer allowances than claimed on your original federal
Form W-4, and the disallowed allowances were claimed on your
original Form IT-2104.
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